Chapter 5 – Trends in Contraception
lia: differentials, trends and assessment of data sourcesuth Wales and Australia: differentials, trends and assessment of data sources
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87 Chapter 5 – Trends in Contraception
FPNSW : Reproductive and sexual health in New South Wales and Australia: differentials, trends and assessment of data sources
Introduction
Access to effective contraception is essential for optimal reproductive and sexual health. It allows for the planning of the number and spacing of pregnancies as well as the prevention of unplanned pregnancies.1 For healthcare providers, monitoring
population trends in contraception use, knowledge and preferences is essential for the provision of effective contraceptive services, especially given the increasing array of products and methods available. A thorough understanding of the methods of contraception used across the population, the factors predicting or directing contraceptive choices, and differences geographically and in specifi c population sub-groups is essential for maintaining and improving reproductive and sexual health.
A wide range of contraceptives is currently available in Australia (Table 5.1). With the exception of emergency contraception and barrier methods such as condoms, most require a prescription from a medical practitioner and are thus not available over-the-counter (OTC).
The availability of a range of contraceptive products provides options for users that can better support preferences related to method of use, prescribed versus OTC availability, reversibility or permanence, the requirement for daily or less frequent action, effectiveness and mitigation of side effects. Potential benefi ts can extend to co-management of menstrual symptoms, emergency contraception and, for some methods, protection against sexually transmissible infections (STIs).2-4 The most
benefi cial individual and population-level outcomes require knowledge, both on the part of the consumer and the clinician, so that consumers can be supported to make effective contraceptive choices that best meet their needs and circumstances.
It is highly likely that the range of contraceptive products available will increase. Research continues to explore new and more versatile approaches to contraception, including immunological methods,5 male hormonal contraceptives
including pills, injections and implants,6,7 and effective
on-demand contraception, in particular methods that are accessible and acceptable to younger people.8 However,
these remain in comparatively early development. The information presented in this chapter is based largely on cross-sectional surveys, Medicare claims for Pharmaceutical Benefi ts Scheme (PBS)-listed contraceptives and Medical Benefi ts Scheme (MBS)-listed contraception related procedures:
• The Australian Bureau of Statistics (ABS) 2001 National Health Survey (NHS) prevalence estimates for contraceptive use among women and their partners.9
• The Australian Study of Health and Relationships (ASHR) population health survey undertaken in 2001–2002 which investigated the experiences of 19,307 people aged 16 to 59 years.4,10,11
• The National Survey of Australian Secondary Students and Sexual Health (NSASS) survey of Year 10 and 12 students from more than 100 secondary schools in 2003 (n=2,388 students) and 2008 (n=2,929 students).12,13
• The Australian Longitudinal Study on Women’s Health (ALSWH) longitudinal population-based survey which commenced in 1996 with randomly selected cohorts of women then aged 18 to 23, 45 to 50 and 70 to 75 years. The cohorts were surveyed again in 2000, 2003 and 2006.14
• The Household, Income and Labour Dynamics in Australia (HILDA) national household panel survey on families, income, employment and wellbeing. The survey began in 2001 with 7,682 households at which interviews were conducted on 19,917 participants. Data reported here are from the 2001–2005 surveys.15
• The ABS 2004–2005 National Aboriginal and Torres Strait Islander Health Survey.16
• Medicare data: Pharmaceutical Benefi ts Scheme (PBS) data and Medicare Benefi ts Schedule (MBS) data for contraceptive related procedures (online at: www. medicareaustralia.gov.au/about/stats/index.jsp.)
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Chapter 5 –Trends in Contraception
FPNSW : Reproductive and sexual health in New South Wales and Australia: differentials, trends and assessment of data sources
Table 5.1: Contraception in Australia, 2010
CONTRACEPTIVE METHOD USE PRODUCTS
AVAILABLE
AVAILABILITY*: PBS/MBS/OTC Reversible
Combined hormonal contraceptive pills (containing both
oestrogen and progestogen) Daily 30 PBS: 18
Progestogen-only pills (mini-pills) Daily 2 PBS: 2
Combined hormonal vaginal rings Monthly 1 No
Contraceptive injections Three-monthly 2 PBS: 2
Contraceptive implants Three-yearly 1 PBS: 1
Intrauterine methods:
• copper-bearing non-hormonal intrauterine device (IUD) • hormonal releasing intrauterine system (IUS)
IUD 5 or 10 years IUS 5 years
2 1
IUD not listed IUS MBS/PBS
Barrier methods: condoms (male and female) As required Many OTC
Barrier methods: diaphragms As required 1 OTC†
Natural and safe period methods:
• Billing’s, symptothermal and calendar rhythm to guide periodic abstinence
• withdrawal
• lactational amenorrhoea
As required - -
Permanent
Female tubal ligation - - MBS‡
Female tubal occlusion - 2 MBS‡
Male vasectomy - - MBS‡
Emergency contraception
Emergency contraceptive pills 72 (to 120) hrs of
unprotected sex 3, (2 generic) OTC
§
Intrauterine device Up to 5 days after
unprotected sex 2 No
*PBS = Pharmaceutical Benefi ts Scheme; MBS = Medicare Benefi ts Schedule. Products listed on the PBS or procedures on the MBS are available to the consumer at reduced cost. OTC = Over-the-counter; no prescription is required and products may be available at pharmacies and supermarkets. † Available without prescription but requires a fi tting by a doctor in general practice or at a Family Planning clinic
‡ MBS reimbursement for sterilisation procedure; products reimbursed through Prosthesis List.
§ Over the counter at pharmacies only; not all pharmacies in Australia dispense emergency contraception.
Sources: MBS-Medicare Benefi ts Schedule Book Commonwealth of Australia 2009; PBS-Schedule of Pharmaceutical Benefi ts Commonwealth of Australia 2010.
Chapter 5 – Trends in Contraception
lia: differentials, trends and assessment of data sourcesuth Wales and Australia: differentials, trends and assessment of data sources
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89 Chapter 5 – Trends in Contraception
FPNSW : Reproductive and sexual health in New South Wales and Australia: differentials, trends and assessment of data sources
Data Limitations
There are no routinely collected data on contraceptive use in Australia that are both reliable and complete, and our understanding of trends and patterns of contraceptive use is consequently fragmented and limited. Information is largely derived from survey data, and most of these surveys only included contraception as part of a wider survey scope; i.e. with the exception of the Australian Study of Health and Relationships (ASHR) and National Survey of Australian Secondary Students and Sexual Health (NSASS), reproductive and sexual health in general and contraception in particular were not the primary focus of the survey. The most recent survey data are more than fi ve years old and do not capture comparatively new contraceptive methods such as the implant, vaginal ring and hormonal Intrauterine System (IUS). Comparisons between surveys and over time are limited by differences in the types of contraceptive methods assessed, the terminology and classifi cation of contraceptive methods, and the sampling frames and populations from which the samples were drawn. Surveys may further overestimate the use of condoms, as they rarely differentiate between condom use primarily for contraception or for STI protection.
Household surveys such as the ASHR and Australian Longitudinal Study on Women’s Health (ALSWH) are subject to bias through omitting people who are less likely to be surveyed. For example, surveys based on telephone interviews with households (e.g. ASHR) omit households without a landline telephone and exclude people in colleges, prisons, oil rigs, camps, and hospitals, etc. Adjustment by matching to census demographic profi les can ameliorate or at least identify where biases may be present. The ALSWH was based initially on the Medicare database of Australian citizens and permanent residents, but owing to errors in this database response rates cannot be defi ned exactly (although they are estimated at between 37 and 56%).
The National Survey of Australian Secondary Students and Sexual Health (NSASS) does not include young people who are out of school, who are known to have a lower age at fi rst intercourse and be at greater risk of unplanned pregnancy or STI.17,18
Although regular National Health Surveys have been conducted by the ABS since 1983, the 2004–2005 and 2007–2008 surveys did not include contraceptive practice items. Data on contraceptive use in women aged 18 to 49 years are available from the 1995 and 2001 surveys but are not directly comparable owing to differences in the classifi cation of contraceptive methods.
The ALSWH allows for comparison of oral contraceptive and condom use from 1996 to 2005 but does not contain data on copper intrauterine devices (IUDs), hormonal intrauterine
systems (IUSs) or the vaginal ring. The Household, Income and Labour Dynamics in Australia (HILDA) survey began in 2001, but contraceptive data were collected in 2005 only. No data were collected on hormonal IUSs. The ASHR and NSASS are the only surveys to provide data on contraceptive use in people under the age of 18 years.
The usefulness of analysing Medicare data is limited as government reimbursement is not provided for all contraceptive procedures or products and therefore not all are listed on the Medicare (MBS) or Pharmaceutical (PBS) benefi ts schedules (Table 5.1). The earliest
marketed contraceptive pills containing the progestogens levonorgestrel and norethisterone, either in the form of progestogen-only pills (mini-pills) or as combined pills with ethinyl oestradiol, are listed on the PBS. The hormonal IUS (Mirena®) was listed in 2001 and the contraceptive implant
(Implanon®) in 2003. Newer pills such as those containing
drospirenone (e.g. Yasmin®), as well as the vaginal ring and
copper IUD are not listed. A further limitation is that the PBS data refl ect prescriptions fi lled and are not counts of numbers of users.
MBS claims for intrauterine contraceptive insertions (Medicare Item 35503: Introduction of an Intrauterine Contraceptive Device) and sterilisation procedures can be tracked through the Medicare claims for these services, although these do not include procedures carried out at family planning clinics, for example, which do not bill through Medicare.
Associated socio-demographic or geographic data that might guide the development of relevant policies and services are not reported in Medicare data. Such data that have been collected in surveys are limited, and meaningful comparisons are hampered by the lack of methodological consistency across the surveys. In particular, the service and education needs of groups such as teenagers, rural women and Aboriginal and Torres Strait Islander women are diffi cult to assess and address. Either access to unit records from surveys with more detailed information (e.g. Yusuf and Seidlecky’s 2007 expanded analysis of the ABS 2001 NHS)19
or surveys which report associated data (e.g. the ASHR) are required to widen our understanding of contraceptive behaviour beyond simple estimates of use.
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Chapter 5 –Trends in Contraception
FPNSW : Reproductive and sexual health in New South Wales and Australia: differentials, trends and assessment of data sources